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FORMS

Thank you, for choosing Kendred Wellness Center, PLLC.  We are privileged to have the opportunity to serve you.  The counseling relationship is designed to be one that will facilitate change.  Both the counselor and the client have active roles.  Our role will be to create an environment of trust and warmth, and to give direction.  Your role will be to identify the goals that you would like to have as the focus of your therapy and to examine areas of your life that presently prevent you from meeting your goals. 

Identify the correct forms below, print necessary pages, complete, sign and return them. 

Remember to always maintain copies for your personal records. 

CHILDREN/ADOLESCENT INTAKE PACKET

If you are bringing in a child, please complete the intake packet and bring it to your first therapy session. Bring all legal paperwork if applicable. Please assure that you sign and date all paperwork and initial in designated areas. Make a copy for your personal records.

ADULT INTAKE PACKET

If you're a new client, please complete the intake packet and bring it to your first therapy session. Please assure that you sign and date all paperwork and initial in designated area. Make a copy for your personal records.

AUTHORIZATION TO DISCLOSE HEALTH INFORMATION

Individuals requesting a copy of their medical records must complete and submit this form; please allow 15 days for any releases to be processed. If you need the information sooner please contact us.

AUTHORIZATION TO CONSENT TO TREATMENT OF A MINOR

Parents and/or guardians are to complete the authorization to consent for treatment of minor if they are unable to bring in a minor (anyone under the age of 18) to compete a session; this form must be completed and returned prior to session along with a copy of the guardians identification along with the individual that will be bringing them child in for services. Identification will be verified.

ACKNOWLEDGEMENT OF SERVICE/ CONSENT FORMS

Parents and/or guardians are to complete the HIPPA authorization forms and additional consents; these forms must be completed and returned prior to session along. All pages must be signed, dated and initialed where requested.

Forms: List
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